The relationship between sleep disorders and aggressive behaviour among schizophrenia patients in the community: A moderated mesomeric effect model

doi:10.21203/rs.3.rs-3225208/v1

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Research Article

The relationship between sleep disorders and aggressive behaviour among schizophrenia patients in the community: A moderated mesomeric effect model

https://doi.org/10.21203/rs.3.rs-3225208/v1

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Objective

Sleep disorder is the most common complaint of patients with schizophrenia, which can not only lead to poor prognosis and low survival rate but also aggressive behaviour, posing a significant threat to social security and stability. The aim of this study is to explore the mediating role of depression in the relationship between sleep disorders and aggressive behaviour in people with schizophrenia living in the community, as well as the regulatory role of family intimacy and adaptability. These findings, in turn, may provide a theoretical basis and constructive suggestions for resolving the physical and mental health problems of these patients.

Method

A convenience sampling method was used to select schizophrenia patients from Pengzhou City, China, for follow-up, and a survey was conducted on the Questionnaire Star platform. The survey included questions about general demographic data and disease-related questionnaires: the Pittsburgh Sleep Quality Index (PSQI), the Modified Over Aggression Scale (MOAS) revised Chinese version, the Self-Rating Depression Scale (SDS), and the Family Adaptability and Cohesion Scale, Second Edition. FACES-II and SPSS 21.0 were used to organize and analyse the data.

Results

A total of 818 schizophrenia patients living in the community participated in the survey, and 785 valid questionnaires were ultimately collected for a response rate of 95.97%. The results of multivariate analysis indicate that gender, psychiatric medication use, outpatient follow-up, and sleep disorders are the factors influencing aggressive behaviour. Depression played a partial mediating role between sleep disorders and aggressive behaviour, and the indirect effect size value was 0.043 (57.33% of the total). Sleep disorders and family intimacy (β=-0.009, P < 0.01) and adaptability (β=-0.145, P < 0.001) can significantly predict depression.

Conclusion

1. The incidence of aggressive behaviour and sleep disorders in patients with schizophrenia living in the community is low. 2. Depression plays a partial mediating role in the relationship between sleep disorders and aggressive behaviour. 3. Family intimacy and adaptability play a regulatory role between depression and sleep disorders.

Schizophrenia

Sleep disorders

Aggressive behaviour

depressed

Schizophrenia (SZ) is a common psychiatric disorder characterized by cognitive, emotional, and behavioural disorders [1]. The WHO survey results show that the global incidence of schizophrenia is 0.6–1.0%, and the number of patients with schizophrenia accounts for approximately 50% of the total number of individuals with mental illnesses [2, 3]. Moreover, the incidence of schizophrenia in China has been increasing yearly [4]. According to data released by the National Health and Family Planning Commission, as of the end of 2016, there were approximately 5.4 million registered patients with severe mental disorders nationwide, of which approximately 3/4 were schizophrenia patients. At the same time, there were approximately 5 million nonhospitalized schizophrenia patients, accounting for 90% of the total number of schizophrenia patients [5]. A study found that the incidence of aggressive behaviour among schizophrenia patients in community clinics was 20%, while in nursing homes, it was 40%-60% [6]. Clinical manifestations of schizophrenia include behavioural disorders, thinking disorders, delusions, fantasies, and sleep disorders. Among them, 10% of schizophrenia patients exhibit aggressive behaviour in the community, while only 2% of healthy individuals do so [7]. The incidence of aggressive behaviour in Chinese patients with schizophrenia is 40.2% [8]. The aggressive behaviour of schizophrenic patients may be a response to psychotic delusions, hallucinations, or misunderstandings. Due to the recurrence of the disease and the continuous deterioration of the condition, patients with schizophrenia can engage in behaviours that endanger their own or others' physical and mental safety, such as suicide and aggressive behaviour, and these behaviours can cause trouble. According to reports, patients with schizophrenia are 20 times more likely to kill people than the general population. There is a significant threat to social security and stability [9]. Patients with mental disorders require long-term or repeated hospitalization, which poses a serious economic burden to society and families [10, 11]. Related studies have found that patients with schizophrenia who live in the community are more likely to engage in aggressive behaviour and pose a higher threat to society than hospitalized patients [12]. Therefore, the prevention and treatment of aggressive behaviour among schizophrenic patients in the community has become a key concern in social medical and health care [13].

Sleep disorder is the most common symptom experienced by patients with schizophrenia, with 30%-80% of patients experiencing sleep disorders. A study conducted on outpatient patients with schizophrenia showed that 44% of patients have insomnia symptoms [14, 15]. Sleep disorders can lead to a decrease in the quality of life and cognitive impairment in patients with schizophrenia. At the same time, patients with schizophrenia can experience adverse emotional reactions, and in severe cases, it can lead to self-harm or even suicidal tendencies, ultimately affecting the individual’s prognosis [16]. Demichelis OP [17] found through a meta-analysis exploring the relationship between sleep and aggressive behaviour that sleep deprivation in the general population is associated with increased levels of aggression. Another meta-analysis pointed out that individuals with schizophrenia have higher aggression due to poor sleep quality, and the results showed a correlation of 0.28 (95% CI 0.25–0.31; I2 = 90.1%) [18]. In summary, conducting research on sleep disorders and aggressive behaviour in schizophrenia patients living in the community has important public health significance for preventing aggressive behaviour.

Therefore, this study attempts to make the following hypothesis: Hypothesis 1: Sleep disorders are a risk factor for aggressive behaviour in individuals with schizophrenia.

The mediating role of depression between sleep disorders and aggressive behaviour

Schizophrenia can trigger various negative psychological states, among which depression is most common, Approximately 30–70% of patients with schizophrenia have depression. Depression seriously affects the physical and mental health of patients, and they exhibit repressed emotions, self-blame, worldliness, and even extreme behaviours such as self-harm and suicide [19], which promote the progression of the patient's condition and further exacerbate the family and socioeconomic burden [20]. Patients with severe mental disorders have a higher risk of suicide attempts and recurrence of emotional attacks due to sleep disorders [21–23]. Ned H found a correlation between sleep quality and depression through sleep- and depression-related treatments in patients with schizophrenia [13]. Meanwhile, Laskemoen JF [24] found that sleep disorders in individuals with schizophrenia are accompanied by severe depressive symptoms. Many longitudinal studies have shown that insomnia is not only a precursor to depression but also an independent risk factor for depression [25, 26]. Insomnia is also considered an important predictor of depression recurrence in patients [25].

Clinical studies have shown that patients with depression are three times more likely to commit violent crimes than the general population, but this is often overlooked by society, as people often focus on the tendency and behaviour of self-harm and suicide in depression patients and overlook their violent aggressive behaviour[27]. Research has shown that suicidal behaviour also increases the risk of attacking others [28, 29] Du Wei's research found that individuals are more likely to attribute negative things to others, generating hostility and blame when tested with negative situational images [30]. There is literature on the relationship between depression and aggression, including dual failure models, performance models, and bidirectional relationship models. Among them, the performance model suggests that depression may lead to aggressive behaviour. Glaser (1967) [31] proposed a performance model through clinical research, believing that emotional issues such as depression can alter an individual's performance behaviour, often resulting in angry emotions that are expressed in their behaviour. Lesse (1974) [32] expanded this model and believed that covert depression would lead to problems such as noncompliance and temper tantrums.

Therefore, this study attempts to make the following hypothesis: Hypothesis 2: Depression plays a mediating role between sleep disorders and aggressive behaviour.

The regulatory role of family intimacy and adaptability between sleep disorders and aggressive behaviour

The family is the first microecological environment that affects individual development, not only directly affecting various aspects of socialization but also playing a crucial role in the healthy development of individual psychology[33]. At present, home care is the main care for patients with mental disorders in China [34]. Olson et al.’s [35] arch pole model suggests that family environment and family function are concentrated in two aspects: family intimacy and adaptability. The theory of family functional patterns suggests that emotional mutual support among family members contributes to the full realization of basic family functions [36]. According to ecological systems theory, the full play of family functions has a significant impact on the development of individual psychological characteristics, which is conducive to the development of individual physical and mental health and the cultivation of a healthy personality [37]. Park YY [38] found that higher family adaptability and intimacy can reduce anxiety and depression levels in cancer patients, indicating that the higher family adaptability and intimacy are, the lower the patient's depression level. There is evidence to suggest that poor family function is one of the predictive factors for the course of recurrent depression [39]. Du N [40] found that family members are more likely to experience depression after their family function decreases. Pérez Fuentes MDC [41] found that family function scores were higher in nonaggressive subjects than in attackers. Moreover, domestic and foreign studies have found that the factors affecting aggressive behaviour in schizophrenia mainly include individual factors and family social factors [41, 42].

Therefore, this study proposes the following hypothesis: Hypothesis 3: Family intimacy and adaptability play a regulatory role between sleep disorders and aggressive behaviour.

At present, although there have been studies confirming the relationship between sleep quality and aggressive behaviour in patients with schizophrenia, there is relatively little research on community-based schizophrenia. In addition, there are currently no relevant research reports on the relationship between sleep disorders and aggressive behaviour or depression in patients with schizophrenia. There are different pathways through which sleep disorders can cause aggressive behaviour. Psychological problems are often important mediating factors, and family function may play a regulatory role. Protecting the physical and mental health of individuals with schizophrenia is of great significance for maintaining social security and stability. Therefore, this study aims to explore the impact of sleep disorders on aggressive behaviour in patients with schizophrenia in the community from a psychological perspective. Further, the mediating role of depression and the regulatory role of family adaptability and intimacy are examined to provide empirical support and theoretical guidance for interventions for aggressive behaviour. Figure 1 illustrates the proposed moderated mediation model.

Design and participants

This study used a convenience sampling method to select patients with schizophrenia from the Pengzhou community in Chengdu, China. The study survey was distributed on the Questionnaire Star platform. The inclusion criteria were as follows: ① aged ≥ 18 years old; ② diagnosed by two attending psychiatrists or meeting the criteria for schizophrenia in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [43]; ③ evaluated by a psychiatrist and currently in remission with a total score of the positive and negative symptom scales < 60 points, a stable condition and ability to cooperate with this study; ④ found to have normal cognitive function; and ⑤ voluntarily signed an informed consent form. Exclusion criteria were as follows: ① additional mental, neurological, or brain developmental disorders, severe trauma or physical diseases; and ② a history of drug or alcohol dependence. This study was approved by the Ethics Committee of Chengdu Fourth People's Hospital with review number [2017] Ethical Examination Number (16) and China Clinical Trial Registration Number: ChiCTR1800015219.

The survey included questions about general demographic characteristics, sleep, depression, aggressive behaviour, family cohesion and adaptability. The responses to questions about sleep, depression, aggressive behaviour, family intimacy, and adaptability were evaluated using relevant scales. A total of 818 people participated in the survey. After excluding participants who took less than 10 minutes to complete the survey, 785 valid questionnaires were collected for an effective rate of 95.97%.

Outcomes

General demographic characteristics

The general demographic characteristics reported by participants included gender, BMI, family residence, occupation, family monthly income (yuan), marital status and smoking status.

Sleep

The Pittsburgh Sleep Quality Index (PSQI) [44] was used to assess the sleep quality of the subjects. The scale consists of 18 items, including 3 blank filling questions, 5 Multiple choice questions and 10 self-assessment questions. The total score of the scale is composed of seven factors, including sleep quality, sleep time, falling asleep to time sleep efficiency, Sleep disorder, hypnotics and daytime dysfunction. The total score ranges of this scale is 0–21 points, and the higher the score is, the poorer the sleep quality of the study subjects is; If the total score of the scale is higher than 7, Sleep disorder will be judged.

Aggressive behaviour

The revised Chinese version of the Explicit Offensive Behavior Scale (MOAS) was used to assess aggressive behaviours. The scale includes four types of attack subscales: verbal attack, assault on property, self-attack, and assault on others. Each subscale is rated on a 5-point Likert scale (0–4), with a higher score indicating a greater number and severity of aggressive behaviours [45].

Depressed

This study used the Self-Rating Depression Scale (SDS) [46] to assess the depression status of the study subjects. This scale mainly measures the self-perception of depression in the past week and consists of 20 items measured on a 4-point Likert scale, with items 1, 2, 3, 7, 8, 9, 10, 15, and 19 being positive scores. The total score of this scale ranges from 0–80 points, and the higher the score is, the more severe the depressive mood of the study subjects.

Family intimacy and adaptability

The Family Intimacy and Adaptability Scale was developed by Olsen et al. in 1982 and translated and revised into Chinese by Fei LP et al[47]. in 1991. It includes two parts, Family Intimacy and Family Adaptability, with a total of 30 items. Using a 5-point Likert scale, "not", "occasionally", "sometimes", "often", and "always" are scored 1, 2, 3, 4, and 5 points, respectively. The higher the score is, the better the family intimacy and adaptability. The internal consistency of this scale is Cronbach’s α, which ranges from 0.68 to 0.85.

Statistical analysis

This study used Epidata3.1 software to input and organize data, and SPSS 21.0 and process software were used to analyse and process the data. The descriptive analysis method was used to analyse the general demographic characteristics of the research subjects. The univariate analysis of aggressive behaviour and sleep disorders in schizophrenia was conducted using the χ² test, while the multivariate analysis of sleep disorders in schizophrenia was conducted using binary logistic regression analysis. The bootstrap method was used to test the mediating regulatory effect in the study. The difference was statistically significant at p < 0.05.

Basic information and correlation analysis of the research object

The study population consisted of 414 males (52.74%) and 371 females (47.26%). There were 132 people with sleep disorders, accounting for 16.82% of the total surveyed population. The proportion of schizophrenia patients with aggressive behaviour was 13.63%.

By comparing the incidence of aggressive behaviour and sleep disorders among people with different demographic characteristics, it was found that the incidence of aggressive behaviour in women was higher than that in men (P < 0.05), but the incidence of sleep disorders did not differ between men and women (P > 0.05). The incidence of aggressive behaviour in patients with schizophrenia who had used psychiatric drugs within the past 3 months was higher than that in those who had not used them, and the difference was statistically significant (P < 0.05). However, the difference in the incidence of sleep disorders between the two groups was small (P > 0.05). The incidence of aggressive behaviour in patients with schizophrenia who had undergone psychological treatment within the past 3 months was higher than that in patients who had not experienced it (P < 0.05), and there was no difference in the incidence of sleep disorders between the two groups (P > 0.05). The incidence of sleep disorders in patients who smoked was higher than that in nonsmokers (P < 0.05), and there was no difference in the incidence of aggressive behaviour between the two groups (P > 0.05), as shown in Table 1.

Multivariate analysis of aggressive behaviour in patients with schizophrenia living in the community

Using the presence or absence of aggressive behaviour as the dependent variable and statistically significant variables in univariate analysis as independent variables, they were collectively included in binary logistic regression analysis. Stepwise regression was used to screen the independent variables and enter the model α = 0.05 and eliminate the model α = 0.10. The results showed that gender, use of psychiatric drugs, number of outpatient follow-up visits, and sleep disorders were all influencing factors for the occurrence of aggressive behaviour in the survey subjects. Among them, aggressive behaviour was more frequent than nonaggressive behaviour, with an OR of 2.328 (1.446, 3.749). The parameter estimates and hypothesis testing results of each variable included in the model are detailed in Table 2.

Table 1

Aggressive behaviour and sleep disorders with different demographic characteristics(N = 785)
Variable		n	Aggressive behaviour			Sleep disorders
Variable		n	n(%)	χ χ²	p	n(%)	χ²	p
Sex
	Male	414	40(9.66)	11.720	0.001	66(15.94)	0.478	0.490
	Female	371	67(18.06)			66(17.79)
BMI(kg/cm2)
	Thin	39	7(17.95)	0.816	0.665	7(17.95)	0.174	0.917
	Normal	329	46(13.98)			57(17.33)
	Overweight and obesity	317	54(17.03)			68(21.45)
Place of residence
	Rural area	669	97(16.95)	3.863	0.145	113(16.89)	5.973	0.05
	Town	86	9(10.47)			9(10.47)
	City	30	1(3.33)			1(3.33)
Career
	Not have	555	77(16.11)	5.858	0.053	91(16.40)	0.559	0.756
	Have	93	6(6.45)			66(70.97)
	Other	137	24(17.52			26(18.98)
Monthly income (yuan)
	~ 1000	290	46(15.86)	5.199	0.158	42(14.48)	1.745	0.627
	1001 ~ 3000	402	51(12.69)			67(16.67)
	3001 ~ 5000	99	9(9.09)			21(21.21)
	5000~	14	1(7.14)			2(14.29)
Marital status
	Unmarried	258	29(11.24)	5.62	0.229	33(12.79)	7.073	0.132
	Married	374	55(14.71)			73(19.52)
	Divorce	127	18(14.17)			24(18.90)
	Bereft of one's spouse	18	2(11.11)			1(5.56)
	Other	8	3(37.50)			1(12.50)
Smoking history
	No	580	81(13.97)	0.438	0.803	86(14.83)	4.278	0.039
	Yes	205	26(12.68)			46(22.44)
History of use of psychiatric drugs
	No	653	74(12.78)	17.423	0.000	111(17.00)	0.093	0.760
	Yes	132	33(25.00)			21(15.91)
History of Psychotherapy
	No	756	99(13.10)	4.982	0.026	131(14.68)	2.918	0.088
	Yes	29	8(27.59)			1(3.45)
MECT treatment history
	No	778	106(13.62)	0.000	1.000	131(16.84)	0.000	1.000
	Yes	7	1(14.29)			1(14.29)
Outpatient follow-up frequency
	More than usual	25	7(28.00)	35.6	0.000	5(20.00)	0.226	0.893
	Less than usual	227	54(23.79)			37(16.30)
	As usual	533	46(8.63)			90(16.89)
Hospitalization history of mental disorders
	No	733	95(12.96)	4.221	0.04	127(17.32)	2.064	0.151
	Yes	52	12(23.08)			5(9.62)

Table 2

Multivariate analysis of factors influencing aggressive behaviour in patients with schizophrenia living in the community
Variable		B	S.E.	Wald	p	OR	OR 95% CI
Variable		B	S.E.	Wald	p	OR	Lower limit	Upper limit
Sex	Female/Male	0.866	0.224	14.951	0.000	2.378	1.533	3.688
History of use of psychiatric drugs	Yes/No	0.772	0.310	6.207	0.013	2.164	1.179	3.972
Outpatient follow-up frequency	More than usual/As usual/Less than usual	-0.543	0.251	4.663	0.031	0.581	0.355	0.951
Hospitalization history of mental disorders	Yes/No	1.197	0.375	10.160	0.001	3.310	1.586	6.909
Sleep disorders	Yes/No	0.890	0.252	12.497	0.000	2.435	1.487	3.388
Constant term		-3.928	0.772	25.916	0.000	0.020	-	-
Note: the two categorical variable are assigned with values: sex = 1, female = 2, history of use of psychotropic drugs = 0, presence = 1, outpatient follow-up times 1 = more than usual, 2 = the same as usual, 3 = less than usual, psychiatric hospitalization history = 0, presence = 1, sleep disorder absence = 0, presence = 1.

Mesomeric effect of depression on the relationship between aggressive behaviour and sleep in schizophrenic patients

This study further explores the relationship between sleep disorders, aggressive behaviour, and depression in patients with schizophrenia. Using the plug-in Process in SPSS21.0 to analyse the mesomeric effect, aggressive behaviour as an independent variable, depression as a mediating variable, and sleep disorders of schizophrenic patients as a dependent variable were put into model 4. Bootstrapping was used for testing, and 5000 bootstrap samples were set to build a mesomeric effect model. The results showed that there was a statistically significant association between aggressive behaviour, depression, and sleep disorders in patients with schizophrenia. See Table 3.

Table 3

Regression analysis between variables
		β	SE	T	95% confidence interval
					LLCI	ULCI	R²	F
Depressed	Constant	1.068	0.132	8.085^***	0.809	1.328	0.223	224.741^***
	Sleep disorders	0.400	0.027	14.991^***	0.348	0.453
Aggressive behaviour	Constant	0.017	0.061	0.283	-0.103	0.138	0.045	36.946^***
	Sleep disorders	0.075	0.012	6.078^***	0.051	0.100
Aggressive behaviour	Constant	0.098	0.062	-1.569	-0.220	0.025	0.096	41.663^***
	Depressed	0.108	0.016	6.589^***	0.076	0.139
	Sleep disorders	0.032	0.014	2.360^*	0.005	0.059
Note: β: Regression coefficient, : P < 0.05, : P < 0.01, * *: P < 0.001

The analysis results show that the percentile bootstrap confidence interval of indirect effects does not contain 0 (0.014, 0.076), indicating that there is a mesomeric effect. The percentile bootstrap confidence interval of the direct effect does not contain 0 (0.005, 0.059), indicating that there is some mediation between sleep disorder and aggressive behaviour in patients with schizophrenia, and the mesomeric effect accounts for 57.33%. See Table 4.

Table 4

Mesomeric effect test of depression between sleep disorder and aggressive behaviour in schizophrenic patients
Variable	Effect	BootSE	BootCI Lower limit	BootCI Upper limit	Effect proportion(%)
Total effect	0.075	0.012	0.051	0.010	100
Direct effect	0.032	0.014	0.005	0.059	42.67
Indirect effect	0.043	0.016	0.014	0.076	57.33
Note: Boot standard error, Boot CI lower limit, and Boot CI upper limit refer to the standard error, 95% confidence interval lower limit, and upper limit of indirect effects estimated by the deviation corrected percentile Bootstrap method, respectively.

Analysis of the regulatory effects of family intimacy and adaptability on the relationship between sleep disorders and aggressive behaviour in patients with schizophrenia

To further explore the role of depression in the relationship between sleep disorders and aggressive behaviour in patients with schizophrenia living in the community, this study used the plugin Process in SPSS 21.0 to analyse the mediating regulatory effect. Sleep disorders were used as the independent variable, depression was used as the mediating variable, family density and total adaptive score were used as the moderating variables, and aggressive behaviour was used as the dependent variable in Model 59. The bootstrap sample is set to 5000, and a regulated mesomeric effect model is constructed. The results showed that family intimacy and adaptability played a regulatory role in predicting depression through sleep disorders, and family adaptability also played a regulatory role in predicting aggressive behaviour through depression, with statistical significance (P < 0.05). The mediation effect model is shown in Fig. 2.

Further simple slope analysis shown in Fig. 3 indicates that for these patients with lower family intimacy (M-1SD) (such as Z=-1), the upwards trend of depression is significant with the increase of sleep disorder degree (simple slope = 0.40, t = 13.04, p < 0.001). An increase of 1 standard deviation in stress perception leads to an increase of 0.40 standard deviations in depression. For patients with high family intimacy (such as Z = 1), the change in depression remains significant as the degree of sleep disorder increases (simple slope = 0.23, t = 5.34, p < 0.001), but stress perception increased by 1 standard deviation, and depression only increased by 0.23 standard deviations. From Fig. 4, it can be seen that for patients with lower family intimacy (M-1SD) (such as Z=-1), the upwards trend of depression is significant with the increase of sleep disorders (simple slope = 0.50, t = 14.54, p < 0.001), if sleep disorders increase by 1 standard deviation, depression will increase by 0.50 standard deviations. For those patients with high family intimacy (such as Z = 1), as the degree of sleep disorders increases, the changes in depression in are still significant (simple slope = 0.22, t = 5.25, p < 0.001), but sleep disorders increased by 1 standard deviation, while depression only increased by 0.22 standard deviations.

Table 5

Analysis of mesomeric effect of sleep disorders on aggression
Variable	Aggressive behaviour			Depression
Variable	β	S.E	t	β	S.E	t
Sleep disorders	0.035	0.015	2.311^*	0.318	0.030	10.679^***
Depression	0.085	0.019	4.420^***	-	-	-
Intimacy	-0.006	0.042	-1.410	-0.042	0.009	-4.646^***
Sleep disorders×Intimacy	0.002	0.001	1.322	-0.009	0.003	-3.562^**
Depression×Intimacy	-0.003	0.002	-1.960	-	-	-
R ²		0.104		0.256
F		18.036^***		59.667^***
Sleep disorders	0.029	0.014	2.122^*	0.358	0.027	13.123^***
Depression	0.056	0.016	3.031^**	-	-	-
Adaptability	-0.015	0.004	-3.909^**	-0.024	0.082	-3.330^**
Sleep disorders×Adaptability	0.001	0.002	-0.889	-0.145	0.003	-5.133^***
Depression×Adaptability	-0.007	0.002	-3.988^**	-	-	-
R ²	0.141			0.256
F	25.480^***			59.362^***
Note: β: Regression coefficient, S.E: standard error, : P < 0.05, : P < 0.01, *: P < 0.001

This study aims to explore the relationship between sleep disorders and aggressive behaviour in patients with schizophrenia who live in the community and further analyse the mediating role of depression in the relationship between sleep disorders and aggressive behaviour, as well as the regulatory role of family intimacy and adaptability. The results of this study showed that 132 people had sleep disorders, accounting for 16.82% of the total survey population, which is basically consistent with the research results of Robertson I et al[48]. Zang Y [49] found through a survey of patients with schizophrenia living in the community in Guangzhou that their insomnia rate was 28.9%. Therefore, this study also demonstrates that even if such patients are clinically stable, they can still suffer from sleep disorders. The results of this study show that the incidence of sleep disorders in smoking patients is higher than that in nonsmokers, which is consistent with the results of Li DJ et al [50]. Research has confirmed that the blood concentration of antipsychotic drugs in nonsmokers is higher than that in smokers, and the drug clearance half-life and peak concentration in smokers are significantly lower than those in nonsmokers. Therefore, smoking will reduce the efficacy of antipsychotic drugs, leading to more pronounced positive mental symptoms in smokers and thus affecting their quality of sleep [51].

The results of this study showed that there were 106 schizophrenic patients with aggressive behaviour, accounting for 13.63% of the total surveyed population. This is inconsistent with studies such as Araya T [52] (26.6%) and Zhou JS [53](35.4%). The difference in findings may be related to the condition of subjects in this study, who were mostly in remission with mild or atypical mental symptoms, and their self-control may have been stronger than those in the acute stage, resulting in a lower likelihood of aggressive behaviour. Although the incidence of aggressive behaviour among the patients in this study was lower than that of hospitalized patients, the situation of aggressive behaviour among patients with schizophrenia living in the community cannot be ignored. The results of this study show that the incidence of aggressive behaviour in women is higher than that in men. In a study on patients with schizophrenia who engage in aggressive or violent behaviour towards different relatives, males accounted for 81.0% [54], which is inconsistent with the results of this study. The reason may be that in the face of a fiercely competitive society, women's aggressive and bold behaviour may be easier to accept, which can lead to the reinforcement of aggressive behaviour in females [55]. Therefore, the mental health issues of female patients with schizophrenia in the community cannot be ignored. Both males and females, if they have mental health problems, need active psychological counselling to reduce the occurrence of aggressive behaviour.

The results of multivariate analysis showed that sleep disorders among this population were influencing factors for aggressive behaviour. The study subjects with sleep disorders had a more frequent occurrence of aggressive behaviour than those without sleep disorders, with OR = 2.435 (1.487, 3.388), confirming hypothesis 1. Chen ZT [34] found through a survey of patients in the psychiatric outpatient and day ward of a regional teaching hospital that the sleep quality of patients with schizophrenia is associated with potential violence. Meanwhile, Langrud K [56] found through research that a decrease in sleep quality in psychiatric intensive care unit patients can lead to an increase in the risk of aggression, which is consistent with the results of this study. The reasons may be related to sleep disorders leading to sustained activation of the sympathetic nervous system and reduced frontal lobe activity, resulting in patients' lack of concentration and cognitive impairment, which can cause behavioural control problems [57]. The results of this study suggest that community workers, medical staff, and family members should be aware of the negative effects of sleep disorders and aggressive behaviour. At the same time, patients with schizophrenia should be encouraged to actively participate in social activities. If these patients have sleep disorders, the community, medical staff, and family members should have more positive psychological communication with the patients, understand the causes of sleep disorders, and seek timely treatment to improve their sleep quality. This, in turn, may reduce the occurrence of aggressive and even violent behaviour among these patients, promote their mental and psychological health, reduce the burden of family mental stress, and promote social harmony and stability.

Related studies have shown a strong correlation between sleep disorders and mental health issues such as depression [58]. This study validated the mediating role of depression between sleep disorders and aggressive behaviour. The results showed that after adding the variable of depression, both sleep disorders and depression were associated with aggressive behaviour. The regression coefficient of aggressive behaviour decreased from 0.075 to 0.032, and the explanatory degree of the independent variable for the dependent variable increased from 4.5–9.6%. This indicates that depression increased the explanation for the variation in aggressive behaviour by 5.1%. Patients with schizophrenia and depression have a common problem with aggressive behaviour due to their high emotional fluctuations. Yang CR established a depression mouse model in a chronic unpredictable mild stress environment and found that mice exposed to mild emergency showed increased aggression/hostility [59]. Meanwhile, relevant studies have also shown that sleep disorders and depression have a bidirectional relationship and mutual influence [25]. In this situation, patients with depression are highly likely to engage in dangerous behaviours, such as self-injury and suicide. Therefore, regularly observing the changes in patients' conditions, actively listening to their demands, and providing corresponding mental health services can reduce the occurrence of depression.

Wen Zhonglin [60]pointed out that, from a statistical point of view, the interaction between two categorical variables is equivalent to the moderating effect of one independent variable on the path of the other independent variable and dependent variable. As a treatment method for schizophrenia, family psychological education plays an important role in the rehabilitation of patients [61]. The results of this study show that family cohesion and adaptability have significant interactions with depression; that is, the first half of the mesomeric effect path has a significant regulatory role, while family adaptability also has a regulatory role in mediating the second half of the path. In the group with low levels of family intimacy and adaptability, depression can significantly positively predict aggressive behaviour in the patient. However, in the group with high levels of family intimacy and adaptability, the ability of depression to positively predict aggressive behaviour weakens. This indicates that as family intimacy and adaptability increase, the ability of depression to predict aggressive behaviour continues to decrease, which is basically consistent with the research results of Zahra [62] and Fang H [25]. A higher level of family intimacy and adaptability can help individuals avoid aggressive behaviour caused by higher levels of depression. The reason may be that families with low levels of family intimacy and adaptability are prone to various conflicts. However, appropriate family intimacy and adaptability can help promote emotions among family members, create a safe family atmosphere, and promote more happiness for patients with schizophrenia, reducing the occurrence of depression [38]. Therefore, family members should give sufficient care to patients with schizophrenia, understand their thoughts in a timely manner, and create a warm, safe, and loving environment. The community can offer more promotional activities related to mental health, regularly hold mental health lectures, and help patients learn methods to relieve psychological stress and improve their communication skills.

Limitations

The current research has several limitations. First, this is a cross-sectional survey. Although it raises suspicious risk factors for aggressive behaviour among patients with schizophrenia living in the community, it does not consider the time and causal relationship between exposure and outcomes. We are also unable to track the health status of all patients, especially those with poor health conditions. Those suffering from multiple diseases and who are undergoing mandatory treatment, for example, require further longitudinal research. Second, participants were not randomly selected, so the results cannot be generalized to all patients with schizophrenia living in the community. Third, this study only discusses the impact of aggressive behaviour and depression on sleep disorders in patients with schizophrenia. In the future, it is necessary to further explore the impact mechanisms of other psychological variables, such as shame and self-esteem.

Through the analysis of mesomeric effects, this study verified that sleep disorders can directly and indirectly predict aggressive behaviour and that depression can directly predict sleep disorders. At the same time, the interaction between family cohesion and adaptability and depression is significant. Therefore, in the future, community and medical staff should strengthen the assessment and monitoring of violent behaviour and depression in schizophrenic patients, formulate reasonable and effective intervention programs from the perspective of positive psychology, and reduce the rate of sleep disorders and suicide in patients to reduce the psychological pain of patients and promote social harmony.

Acknowledgements

Not applicable.

Author contributions

All authors contributed to conceiving, researching, and writing of this manuscript and approved the submitted version.

Funding

This work was supported by the National Natural Science Foundation of China, China. (Grant No.82001444); Foundation of Nursing Key Laboratory of Sichuan Province, China. (Grant No. HLKF2022-2); Sichuan Science and Technology Program. (Grant No. 2018JY0306); Chengdu Medical Research Project.(

Data Availability

The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.

Ethics statement

The studies involving human participants were reviewed and approved by The Fourth People’s Hospital of Chengdu Ethics Committee. The patients/participants provided their written informed consent to participate in this study.

Consent for publication

Not applicable.

Competing interests

The authors declare no conflict of interest.

Qi H, Zong QQ, An FR, Zhang L, Ungvari GS, Sim K, Park SC, Xiang YT. Treatment Rate of Schizophrenia in China: a Meta-Analysis of Epidemiological Studies. Psychiatr Q. 2020;91(3):863–75.
Chien WT, Chan SW, Morrissey J. The perceived burden among Chinese family caregivers of people with schizophrenia. J Clin Nurs. 2007;16(6):1151–61.
Shinozaki A, Hayashi T, Okamura H. Effects of a Psychoeducation Program for People with Schizophrenia Aimed at Increasing Subjective Well-Being and the Factors Influencing Those Effects: a Preliminary Study. Psychiatr Q. 2020;91(1):45–52.
Lu S, Zhao Y, Liu J, Xu F, Wang Z. Effectiveness of Horticultural Therapy in People with Schizophrenia: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health 2021, 18(3).
Yang Y, Li W, An FR, Wang YY, Ungvari GS, Balbuena L, Xiang YT. Voluntary and Involuntary Admissions for Severe Mental Illness in China: A Systematic Review and Meta-Analysis. Psychiatric Serv (Washington DC). 2020;71(1):83–6.
Margallo-Lana M, Swann A, O'Brien J, Fairbairn A, Reichelt K, Potkins D, Mynt P, Ballard C. Prevalence and pharmacological management of behavioural and psychological symptoms amongst dementia sufferers living in care environments. Int J Geriatr Psychiatry. 2001;16(1):39–44.
Girasek H, Nagy VA, Fekete S, Ungvari GS, Gazdag G. Prevalence and correlates of aggressive behavior in psychiatric inpatient populations. World J psychiatry. 2022;12(1):1–23.
Wu Y, Kang R, Yan Y, Gao K, Li Z, Jiang J, Chi X, Xia L. Epidemiology of schizophrenia and risk factors of schizophrenia-associated aggression from 2011 to 2015. J Int Med Res. 2018;46(10):4039–49.
Caqueo-Urízar A, Fond G, Urzúa A, Boyer L, Williams DR. Violent behavior and aggression in schizophrenia: Prevalence and risk factors. A multicentric study from three Latin-America countries. Schizophr Res. 2016;178(1–3):23–8.
Maneeton N, Maneeton B, Jaiyen N, Woottiluk P, Khemawichanurat W. Prevalence of Aggressive or Violent Behaviour in Thai Patients with Schizophrenia: a Cross-Sectional Study. East Asian archives of psychiatry: official journal of the Hong Kong College of Psychiatrists = Dong Ya jing shen ke xue zhi : Xianggang jing shen ke yi xue yuan qi kan 2019, 29(3):87–90.
Shikuri Y, Tanoue H, Imai H, Nakamura H, Yamaguchi F, Goto T, Kido Y, Tajika A, Sawada H, Ishida Y, et al. Psychosocial interventions for community-dwelling individuals with schizophrenia: study protocol for a systematic review and meta-analysis. BMJ open. 2022;12(4):e057286.
Reynolds G, Portillo C, Serper MR. Predictors of residency status in chronically institutionalized and community dwelling schizophrenia patients. Compr Psychiatr. 2018;86:102–6.
Hunt GE, Large MM, Cleary M, Lai HMX, Saunders JB. Prevalence of comorbid substance use in schizophrenia spectrum disorders in community and clinical settings, 1990–2017: Systematic review and meta-analysis. Drug Alcohol Depend. 2018;191:234–58.
Wang Z, Chen M, Wei YZ, Zhuo CG, Xu HF, Li WD, Ma L. The causal relationship between sleep traits and the risk of schizophrenia: a two-sample bidirectional Mendelian randomization study. BMC Psychiatry. 2022;22(1):399.
Demirlek C, Bora E. Sleep-dependent memory consolidation in schizophrenia: A systematic review and meta-analysis. Schizophr Res. 2023;254:146–54.
Stummer L, Markovic M, Maroney ME. Pharmacologic Treatment Options for Insomnia in Patients with Schizophrenia. Med (Basel Switzerland) 2018, 5(3).
Demichelis OP, Grainger SA, McKay KT, Bourdaniotis XE, Churchill EG, Henry JD. Sleep, stress and aggression: Meta-analyses investigating associations and causality. Neurosci Biobehav Rev. 2022;139:104732.
Van Veen MM, Lancel M, Beijer E, Remmelzwaal S, Rutters F. The association of sleep quality and aggression: A systematic review and meta-analysis of observational studies. Sleep Med Rev. 2021;59:101500.
Hausmann A, Fleischhacker WW. Differential diagnosis of depressed mood in patients with schizophrenia: a diagnostic algorithm based on a review. Acta psychiatrica Scandinavica. 2002;106(2):83–96.
Majadas S, Olivares J, Galan J, Diez T. Prevalence of depression and its relationship with other clinical characteristics in a sample of patients with stable schizophrenia. Compr Psychiatr. 2012;53(2):145–51.
Davies G, Haddock G, Yung AR, Mulligan LD, Kyle SD. A systematic review of the nature and correlates of sleep disturbance in early psychosis. Sleep Med Rev. 2017;31:25–38.
Ritsner M, Kurs R, Ponizovsky A, Hadjez J. Perceived quality of life in schizophrenia: relationships to sleep quality. Qual life research: Int J Qual life aspects Treat care rehabilitation. 2004;13(4):783–91.
Sylvia LG, Dupuy JM, Ostacher MJ, Cowperthwait CM, Hay AC, Sachs GS, Nierenberg AA, Perlis RH. Sleep disturbance in euthymic bipolar patients. J Psychopharmacol (Oxford England). 2012;26(8):1108–12.
Laskemoen JF, Simonsen C, Büchmann C, Barrett EA, Bjella T, Lagerberg TV, Vedal TJ, Andreassen OA, Melle I, Aas M. Sleep disturbances in schizophrenia spectrum and bipolar disorders - a transdiagnostic perspective. Compr Psychiatr. 2019;91:6–12.
Fang H, Tu S, Sheng J, Shao A. Depression in sleep disturbance: A review on a bidirectional relationship, mechanisms and treatment. J Cell Mol Med. 2019;23(4):2324–32.
Morphy H, Dunn KM, Lewis M, Boardman HF, Croft PR. Epidemiology of insomnia: a longitudinal study in a UK population. Sleep. 2007;30(3):274–80.
Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2):193–213.
Li Q, Zhong S, Zhou J, Wang X. Delusion, excitement, violence, and suicide history are risk factors for aggressive behavior in general inpatients with serious mental illnesses: A multicenter study in China. Psychiatry Res. 2019;272:130–4.
Franke I, Shenar R, Nigel S, Otte S, Büsselmann M, Streb J, Dudeck M. [Self-Aggression as Mediator between Depression and Aggression]. Psychiatr Prax. 2019;46(6):332–7.
Du W, Liu JT, Kang GL, Ma N, Zhou XL. The impact of insufficient sleep on interpersonal interaction and its cognitive neural mechanisms Psychological Science 2020, 43(02):438–44.
Glaser K. Masked depression in children and adolescents. Am J Psychother. 1967;21(3):565–74.
Lesse S. Depression masked by acting-out behavior patterns. Am J Psychother. 1974;28(3):352–61.
Zhang Y. Family functioning in the context of an adult family member with illness: A concept analysis. J Clin Nurs. 2018;27(15–16):3205–24.
Chen ZT, Wang HT, Chueh KH, Liu IC, Yang CM. An exploration of the sleep quality and potential violence among patients with schizophrenia in community. Perspect Psychiatr Care. 2021;57(2):648–54.
Olson DH, Russell CS, Sprenkle DH. Circumplex model of marital and family systems: VI. Theoretical update. Fam Process. 1983;22(1):69–83.
Miller IW, Ryan CE, Keitner GI, Bishop DS, Epstein NB. The McMaster Approach to Families: theory, assessment, treatment and research. J Family Therapy. 2010;22(2):168–89.
Bronfenbrenner U. Ecological Systems Theory (1992). 2005.
Park YY, Jeong YJ, Lee J, Moon N, Bang I, Kim H, Yun KS, Kim YI, Jeon TH. The influence of family adaptability and cohesion on anxiety and depression of terminally ill cancer patients. Supportive care in cancer: official journal of the Multinational Association of Supportive Care in Cancer. 2018;26(1):313–21.
Santesteban-Echarri O, MacQueen G, Goldstein BI, Wang J, Kennedy SH, Bray S, Lebel C, Addington J. Family functioning in youth at-risk for serious mental illness. Compr Psychiatr. 2018;87:17–24.
Du N, Ran MS, Liang SG, SiTu MJ, Huang Y, Mansfield AK, Keitner G. Comparison of family functioning in families of depressed patients and nonclinical control families in China using the Family Assessment Device and the Family Adaptability and Cohesion Evaluation Scales II. Annals of clinical psychiatry: official journal of the American Academy of Clinical Psychiatrists. 2014;26(1):47–56.
Pérez-Fuentes MDC, Molero Jurado MDM, Barragán Martín AB, Gázquez Linares JJ. Family Functioning, Emotional Intelligence, and Values: Analysis of the Relationship with Aggressive Behavior in Adolescents. Int J Environ Res Public Health 2019, 16(3).
Tabo A, Aydın E, Yumrukçal H, Yiğit S, Uzun UE, Karamustafalıoğlu O. Longer Duration of Untreated Psychosis Hinders Improvement in Treatment of Chronic Schizophrenia: Community Based Early Intervention is an Evidence Based Option. Commun Ment Health J. 2017;53(8):929–35.
Messent P. DSM-5. Clin Child Psychol Psychiatry. 2013;18(4):479–82.
Kansagra S. Sleep Disorders in Adolescents. Pediatrics. 2020;145(Suppl 2):204–s209.
Zhang XL, Hu JM. Revised explicit aggressive behavior scale for risk behavior assessment in patients with mental illness J Forensic Med 2011, 27(05):342–5.
Zung WW. A SELF-RATING DEPRESSION SCALE. Arch Gen Psychiatry. 1965;12:63–70.
Fei LP, Shen QJ, Zheng YP, Zhao JP, Jiang SA, Wang LW, Wang XD. Preliminary evaluation of the Family Intimacy and Adaptability Scale and the Family Environment Scale - a comparative study of normal and schizophrenic family members Chinese J Mental Health 1991(05):198–202.
Robertson I, Cheung A, Fan X. Insomnia in patients with schizophrenia: current understanding and treatment options. Prog Neuro-psychopharmacol Biol Psychiatry. 2019;92:235–42.
Zang Y. A Study on the Sleep Status and Related Factors of Community Schizophrenic Patients Master'. s degree Southern Medical University; 2014.
Li DJ, Chou LS, Chou FH, Hsu ST, Hsieh KY, Wu HC, Kao WT, Lin GG, Chen WJ, Huang JJ. COVID-related psychological distress fully mediates the association from social impact to sleep disturbance among patients with chronic schizophrenia. Sci Rep. 2021;11(1):16524.
Barnes M, Lawford BR, Burton SC, Heslop KR, Noble EP, Hausdorf K, Young RM. Smoking and schizophrenia: is symptom profile related to smoking and which antipsychotic medication is of benefit in reducing cigarette use? Aust N Z J Psychiatry. 2006;40(6–7):575–80.
Araya T, Ebnemelek E, Getachew R. Prevalence and Associated Factors of Aggressive Behavior among Patients with Schizophrenia at Ayder Comprehensive Specialized Hospital, Ethiopia. BioMed research international 2020, 2020:7571939.
Zhou JS, Zhong BL, Xiang YT, Chen Q, Cao XL, Correll CU, Ungvari GS, Chiu HF, Lai KY, Wang XP. Prevalence of aggression in hospitalized patients with schizophrenia in China: A meta-analysis. Asia-Pacific psychiatry: official journal of the Pacific Rim College of Psychiatrists. 2016;8(1):60–9.
He Y, Gu Y, Yu M, Li Y, Li G, Hu Z. Research on interpersonal violence in schizophrenia: based on different victim types. BMC Psychiatry. 2022;22(1):172.
Dempsey F, Hammond M, Dixon L. Investigating whether controlling and aggressive relationship behaviors are discriminant. Aggressive Behav. 2020;46(5):437–48.
Langsrud K, Kallestad H, Vaaler A, Almvik R, Palmstierna T, Morken G. Sleep at night and association to aggressive behaviour; Patients in a Psychiatric Intensive Care Unit. Psychiatry Res. 2018;263:275–9.
Chester DS, Dzierzewski JM. Sour sleep, sweet revenge? Aggressive pleasure as a potential mechanism underlying poor sleep quality's link to aggression. Emot (Washington DC). 2020;20(5):842–53.
Pandi-Perumal SR, Monti JM, Burman D, Karthikeyan R, BaHammam AS, Spence DW, Brown GM, Narashimhan M. Clarifying the role of sleep in depression: A narrative review. Psychiatry Res. 2020;291:113239.
Yang CR, Bai YY, Ruan CS, Zhou HF, Liu D, Wang XF, Shen LJ, Zheng HY, Zhou XF. Enhanced aggressive behaviour in a mouse model of depression. Neurotox Res. 2015;27(2):129–42.
Wen ZL, Hou JT, Zhang L. Comparison and application of regulatory effect and Mesomeric effect J Psychology2005(02):268–74.
McFarlane WR. Family Interventions for Schizophrenia and the Psychoses: A Review. Fam Process. 2016;55(3):460–82.
Zahra ST, Saleem S. Family cohesion and depression in adolescents: A mediating role of self-confidence. JPMA The Journal of the Pakistan Medical Association. 2021;71(2b):677–80.

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The relationship between sleep disorders and aggressive behaviour among schizophrenia patients in the community: A moderated mesomeric effect model

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Version 1

Abstract

Figures

Introduction

The mediating role of depression between sleep disorders and aggressive behaviour

The regulatory role of family intimacy and adaptability between sleep disorders and aggressive behaviour

Methods

Design and participants

Outcomes

General demographic characteristics

Sleep

Aggressive behaviour

Depressed

Family intimacy and adaptability

Statistical analysis

Results

Basic information and correlation analysis of the research object

Multivariate analysis of aggressive behaviour in patients with schizophrenia living in the community

Mesomeric effect of depression on the relationship between aggressive behaviour and sleep in schizophrenic patients

Discussion

Limitations

Conclusion

Declarations

References

Additional Declarations

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Version 1